306 PSYCHIATRIC ANNALS 36:5 | MAY 2006

M
s. T, a 28-year-old black
woman, presents to the
emergency department
with her mother, 58, who is anxious
and requests that her daughter be
de-hypnotized. Both mother and
daughter rmly believe that some-
one has hypnotized the daughter
with the intention of harming her.
The mother refuses psychiatric eval-
uation for herself.
PATIENT HISTORY
Ms. T was raised along with her
older sister by her mother, while the
father had never been in their lives.
The patient had never been married
and had lived her entire life with
her mother, as opposed to her sister,
who didnt get along with the rest of
the family and lived in and out of the
house. The mother assumed the prin-
cipal responsibilities in the house and
Ms. T was submissive to her, remain-
ing otherwise isolative and not sustain-
ing close relationships with friends.
After nishing high school, Ms.
T began working as a secretary, but
within a few months, she began to ex-
perience delusional thoughts, believ-
ing that somebody had poisoned her
food and had hypnotized her to rape
her. She also exhibited episodes of
agitation and socially withdrawn be-
havior. Reportedly, the mother shared
her daughters beliefs at that time.
The patient could not hold her
job and was hospitalized three times
in 1 year because of her symptoms.
She was prescribed olanzapine and
aripiprazole but was only partially
compliant with these medications.
Neither the mother nor daughter
believed that the daughter was men-
tally ill and did not see the need for
medication for her complaint. The
mother controlled her daughters
medications, and the daughter did
not express disagreement with her
mothers directions. Reportedly, Ms.
Ts mother would try her daughters
medications herself before giving
them to her daughter to be aware of
any adverse effects; on one of these
occasions, the mother developed
sedation and asked her daughter to
stop taking her medications. The
mother did not receive psychiatric
evaluation or treatment and did not
report any medical history.
At presentation in the emergency
department, Ms. T maintained mini-
mal eye contact during an interview,
appeared internally preoccupied,
and requested that she be de-hyp-
notized. She was uncooperative,
A 28-year-old Woman and Her 58-year-old
Mother With a Shared Psychotic Disorder
Nahla Mahgoub, MD; and Asghar Hossain, MD, DFAPA
Editors Note: This monthly presentation describes a
case of a psychiatric disorder, discusses past treatment
attempts, offers options for continuing treatment, and ex-
plains the reasons the solution was selected. Submissions
of interesting psychiatric case reports are welcomed for
this department. Please e-mail soconnor@slackinc.com
for further information.
About the authors: Dr. Mahgoub is fourth-year resi-
dent, Bergen Regional Medical Center, Paramus, NJ. Dr.
Hossain is chief psychiatrist, Bergen Regional Medical
Center; associate professor of psychiatry, Ross Univer-
sity School of Medicine, Dominica; and assistant pro-
fessor of psychiatry, St. Georges University School of
Medicine, Grenada.
Both mother and daughter rmly believe that someone has
hypnotized the daughter with the intention of harming her.
case challenges case challenges
case challenges
308 PSYCHIATRIC ANNALS 36:5 | MAY 2006
fearful, agitated, and suspicious.
Her thoughts were tangential. She
was delusional; she believed that
she had been hypnotized so some-
one could persecute her. She denied
suicidal ideation and perceptual dis-
turbances. She did not have an ad-
ditional history of medical illness or
substance abuse. Family history of
psychiatric illness was denied.
The patients history and symp-
toms suggest thought disorder. Her
prior psychiatric hospitalizations and
presenting symptoms might suggest
an evolving delusional disorder or
schizophrenia. Ms. T was admitted to
the hospital. Her laboratory ndings,
including complete blood count, blood
chemistries, thyroid function tests,
liver function tests, and renal function
tests, were within normal limits, and
urine toxicology was negative.
During her hospital stay, she ini-
tially was combative, evasive, and
resistant to taking medications. She
demanded to leave the hospital and re-
quired medical and physical restraint.
She was isolative at times and request-
ed a private room without a window.
She was prescribed 1 mg daily
of risperidone, titrated gradually
to 2 mg twice a day. She received
psychoeducation and was reluctant
to attend group therapy. She was
discharged after 2 weeks when she
showed improvement in her delu-
sion and her behavior was more
controlled. She was educated to
continue her psychopharmacologic
regimen as an outpatient. She was
discharged home to her mother and
was referred to the outpatient clinic
for follow up. She and her mother
refused referral to integrated com-
munity mental services.
Ten days after patients discharge,
the mother decided to relocate with
her daughter to another state and live
with some relatives. One day before
their ight, they reported to an out-
patient clinic, where Ms. T reported
her compliance with medications. she
was observed to be internally preoc-
cupied and had disorganized thoughts.
She was brought to the emergency de-
partment, but she and her mother left
before she could be examined.
The following day, the two wom-
en were unable to board their plane
because they both believed someone
in the airport had hypnotized the
daughter to harm her. They returned
to the emergency department. Ms.
T. was agitated, mumbling, and talk-
ing to herself, but denied hearing
voices. She exhibited delusional be-
havior, believing that she had been
hypnotized in the airport, and that
someone had given her AIDS.
He mother was crying and re-
questing that the hospital staff
please stop this hypnosis; some-
one wants to harm my daughter and
make her sick.
TREATMENT OPTIONS
These options could be consid-
ered as management strategies for
the clinician:
1. Hospitalize Ms. T for medica-
tion adjustment.
2. Hospitalize the mother for
treatment of delusional disorder.
3. Physically separate the two.
4. Start psychotherapy for both.
TREATMENT CHOICE
Options 1 and 3 were chosen.
Ms. T was readmitted, stabilized on
3 mg of risperidone twice per day,
and received group psychotherapy
and occupational therapy. She re-
ceived psychoeducation about her
diagnosis and was counseled on the
need for adherence to her medication
regimen and outpatient follow-up.
When she subsequently went alone
to the airport, she was able to board
the plane and y to her relatives to
live with them away from her mother.
The mother was recommended for
psychiatric evaluation and treatment
but she refused and reportedly did
not move. After this, the patient was
lost to further follow-up.
DISCUSSION
Shared psychotic disorder, or
folie a deux, was rst described by
Lasegue and Falret in 1877.
1,2
The
disorder was called double insan-
ity and infectious insanity.
1
It
involves two people a dominant
person (primary patient) and a sub-
missive person (patient with shared
psychosis).
3
Most often, the symp-
toms are delusions,
4
and 95% of the
reported cases
1
involve people in the
same family with the same psycho-
social environment.
1,5
The patients history and symptoms suggest thought
disorder. Her prior psychiatric hospitalizations and
presenting symptoms might suggest an evolving
delusional disorder or schizophrenia.
case challenges
PSYCHIATRIC ANNALS 36:5 | MAY 2006 309
In this case, the mother and daughter appeared
to have an enmeshed relationship with each other;
the overprotective mother fostered her daughters
dependence. The onset of symptoms occurred
when the daughter started to work and deal with
the external environment. The daughter was unable
to progress beyond the closeness with her mother
and her social isolation. The mother expressed her
hidden fears about her daughters potential inde-
pendence. Their ego disintegrated, and they devel-
oped the same delusional content. The daughter
was adopting and accepting the psychotic feature
of her mother.
This case showed improvement in short-term
outcome in the person with shared psychosis
(daughter) when antipsychotic medication com-
bined with physical separation of the primary per-
son (mother) and the person with shared psychosis.
Treatment adherence, physical and psychological
separation, psychotherapy for both mother and
daughter, and psychosocial treatment may achieve
better long-term outcome.
REFERENCES
1. Sadock BJ, Sadock VA. Kaplan and Sadocks Synopsis
of Psychiatry. 9th ed. Philadelphia, PA: Lippincott, Wil-
liams, & Wilkins; 2002.
2. Sharon I, Sharon R, Eliyahu Y, Shteynman S. Shared psy-
chotic disorder. eMedicine. August 4, 2005. Available at:
http://www.emedicine.com/med/topic3352.htm. Accessed
April 5, 2006.
3. American Psychiatric Association. Diagnostic and Statis-
tical Manual of Mental Disorders [text revision]. 4th ed.
Washington, DC: American Psychiatric Publishing; 2000.
4. Wehmeier PM, Barth N, Remschmidt H. Induced delusion-
al disorder. a review of the concept and an unusual case of
folie a famille. Psychopathology. 2003;36(1):37-45.
5. Silveira JM, Seeman MV. Shared psychotic disorder:
a critical review of the literature. Can J Psychiatry.
1995;40(7):389-395.
6. Mentjox R, Van Houten CA, Kooiman CG. Induced
psychotic disorder: clinical aspects, theoretical consid-
erations, and some guidelines for treatment. Compr Psy-
chiatry. 1993;34(2):120-126.
case challenges